by Bandy X. Lee
THE ISSUE IS DANGEROUSNESS, NOT MENTAL ILLNESS
JAMES GILLIGAN, M.D.
Psychiatrists in America today have been told by two different official organizations that they have two diametrically opposite professional obligations, and that if they violate either one, they are behaving unethically. The first says they have an obligation to remain silent about their evaluation of anyone if that person has not given them permission to speak about it publicly. The second says they have an obligation to speak out and inform others if they believe that person may be dangerous to them, even if he has not given them permission to do so. The first standard is the Goldwater rule of 1973, which prohibits psychiatrists from offering a professional opinion in public about the mental health of anyone whom they have not personally examined. The second is the Tarasoff decision, which in 1976 ruled that psychiatrists have a positive obligation to speak out publicly when they have determined, or should have determined, that an individual is dangerous to another person or persons, in order both to warn the potential victim(s) of the danger they are in and to set in motion a set of procedures that will help protect the potential victim(s).
From both an ethical and a legal standpoint, the second of those two rulings trumps the first.
Insofar as psychiatrists function as clinicians, their primary duty is to their individual patients. Yet, psychiatry, like every other medical specialty, involves more than just clinical practice (that is, diagnosing and treating one patient at a time after those patients have already become ill). It is also a branch of public health and preventive medicine, and in that aspect of its functioning, we owe society a primary duty, for that is the level at which primary and secondary prevention can prevent individuals from becoming ill or violent in the first place, and injuring or killing others if either their illness or their behavior is contagious. In fact, this level of intervention can even prevent the whole society from becoming vulnerable to epidemics of illness, injury, and death. Clinical psychiatry, from a public health standpoint, is merely tertiary prevention, and it represents the least useful contribution we can make to the public health, compared to primary and secondary prevention (Gilligan 2001). From that standpoint, we have a positive obligation to warn the public when we have reason to believe, based on our research with the most dangerous people our society produces, that a public figure, by virtue of the actions he takes, represents a danger to the public health—whether or not he is mentally ill.
An intellectual precursor to the Goldwater rule was a comment that one of the most influential and brilliant German intellectuals made not long before the rise of Hitler. In his essay on “Science as a Vocation,” Max Weber (1917) argued that intellectuals and scholars should not utter political opinions or say anything that could be regarded as “partisan.” They could talk about politics in general, but they should not say anything that could be taken as support for or opposition to any particular party or politician.
I have always been troubled by that opinion, because it appears to me to have encouraged the intellectual and professional leaders of Germany to remain silent, even in the face of enormous and unprecedented danger. It does not seem to me that the German Psychiatric Association of the 1930s deserves any honor or credit for remaining silent during Hitler’s rise to power. On the contrary, it appears from our perspective today to have been a passive enabler of the worst atrocities he committed—as were most German clergymen, professors, lawyers, judges, physicians, journalists, and other professionals and intellectuals who could have, but did not, speak out when they saw a blatantly obvious psychopath gaining the power to lead their country into the worst disaster in its history. Our current president does not have to be a literal reincarnation of Hitler—and I am not suggesting that he is—in order for the same principles to apply to us today.
The issue that we are raising is not whether Trump is mentally ill. It is whether he is dangerous. Dangerousness is not a psychiatric diagnosis. One does not have to be “mentally ill,” as both law and psychiatry define it, in order to be dangerous. In fact, most mentally ill people do not commit serious violence, and most violence is committed by people who are not mentally ill. The association between violence and mental illness is very tenuous at best. Only about 1 percent of the perpetrators of homicide in this country are found to be “not guilty by reason of insanity.” The rest are declared by our courts to be mentally healthy but evil, as those concepts are used in relevance to people’s “criminal responsibility” for whatever violence they have committed.
President Trump may or may not meet the criteria for any of the diagnoses of mental disorders defined in the Diagnostic and Statistical Manual of the American Psychiatric Association, or for many of them, but that is not relevant to the issue we are raising here.
Also, the most reliable data for assessing dangerousness often do not require, and are often not attainable from, interviewing the individuals about whom we are forming an opinion. Such individuals often (though not always) deny, minimize, or attempt to conceal the very facts that identify them as being dangerous. The most reliable data may come from the person’s family and friends and, just as important, from police reports; criminal histories; medical, prison, and judicial records; and other publicly available information from third parties. However, in Trump’s case, we also have many public records, tape recordings, videotapes, and his own public speeches, interviews, and “tweets” of his numerous threats of violence, incitements to violence, and boasts of violence that he himself acknowledges having committed repeatedly and habitually.
Sometimes a person’s dangerousness is so obvious that one does not need professional training in either psychiatry or criminology to recognize it. One does not need to have had fifty years of professional experience in assessing the dangerousness of violent criminals to recognize the dangerousness of a president who:
• Asks what the point of having thermonuclear weapons is if we cannot use them. For example, in an interview with Chris Matthews on an MSNBC town hall meeting, he said, “Somebody hits us within ISIS, you wouldn’t fight back with a nuke?” When Matthews remarked that “the whole world [is] hearing a guy running for president of the United States talking of maybe using nuclear weapons. No one wants to hear that about an American president,” Trump replied, “Then why are we making them?” Another MSNBC host, Joe Scarborough, reported that Trump had asked a foreign policy adviser three times, “If we have them, why can’t we use them?” (Fisher 2016).
• Urges our government to use torture or worse against our prisoners of war. Throughout his presidential campaign, Trump repeatedly said that “torture works,” and promised to bring back “waterboarding” and to introduce new methods “that go a lot further.” After being reminded that there were by then laws prohibiting these practices, he responded by insisting that he would broaden the laws so that the United States would not have to play “by the rules,” as ISIS did not do so (Haberman 2016).
• Urged that five innocent African American youths be given the death penalty for a sexual assault even years after it had been proven beyond a reasonable doubt to have been committed by someone else. In 1989, Trump spent $85,000 placing ads in New York City’s four daily papers calling for the return of the death penalty to New York State so that five African American youths who had been wrongfully convicted of raping a woman in Central Park could be executed, and he was still advocating the same penalty in 2016, fourteen years after DNA evidence and a detailed confession had proved that a serial rapist had actually committed the crime (Burns 2016).
• Boasts about his ability to get away with sexually assaulting women because of his celebrity and power. Trump was recorded saying, of his way of relating to women, that “I just start kissing them. It’s like a magnet.… I don’t even wait. And when you’re a star they let you do it. You can do anything. Grab ’em by the pussy. You can do anything” (“Donald Trump’s Lewd Comments About Women” 2016).
• Urges his followers at political rallies t
o punch protesters in the face and beat them up so badly that they have to be taken out on stretchers. In an editorial, the New York Times has quoted the following remarks by Trump at his rallies: “I’d like to punch him in the face, I’ll tell you”; “In the good old days this doesn’t happen, because they used to treat them very, very rough”; “I love the old days. You know what they used to do to guys like that when they were in a place like this? They’d be carried out on a stretcher, folks”; “If you see somebody getting ready to throw a tomato, knock the crap out of them, would ya? Seriously. Just knock the hell out of them. I will pay for the legal fees, I promise you.” He even complained that his supporters were not being violent enough (even though many had assaulted protesters severely enough to be arrested and tried for assault and battery): “Part of the problem, and part of the reason it takes so long [to remove protesters], is because nobody wants to hurt each other anymore, right?” (New York Times Editorial Board 2016).
• Suggests that his followers could always assassinate his political rival, Hillary Clinton, if she were elected president or, at the very least, throw her in prison. He has led crowds in chants of “Lock her up! Lock her up!” In his words, “If she gets to pick her judges, nothing you can do, folks. Although the Second Amendment people—maybe there is, I don’t know” (remark made during rally on August 9, 2016).
• Believes he can always get away with whatever violence he does commit. He said, “I could stand in the middle of Fifth Avenue and shoot somebody, and I wouldn’t lose voters” (remark made at rally on January 23, 2016).
And so on and on and on—in an endless stream of threats of violence, boasts of violence, and incitements to violence.
While Trump has not yet succeeded in undoing the rule of law to such a degree as to become a dictator, it is clear that he speaks the language of dictatorship. Only dictators assassinate or imprison their personal political rivals and opponents.
Trump did not confess that he personally assaulted women himself; he boasted that he had. That is, he acknowledged having done so repeatedly, and gotten away with it, not as an expression of personal feelings of guilt and remorse for having violated women in this way but, rather, as a boast about the power his celebrity had given him to force women to submit to his violations of their dignity and autonomy.
As for inciting violence by his followers against his enemies, he sometimes used the same tactic that Henry II used to incite his followers to assassinate Thomas Becket, by implication rather than by an explicit order: “What miserable … traitors have I nourished and promoted in my household, who let their lord be treated with such shameful contempt by a low-born clerk!” Of course, his vassals got the point, and did what Henry had made clear he wanted done.
In this regard, however, Trump sometimes went further than his historical predecessors and explicitly, rather than implicitly, encouraged his followers to “punch protestors in the face,” and “beat them up so badly that they’ll have to be taken out on stretchers.” Indeed, a number of his supporters did assault anti-Trump dissenters, and are now being tried for assault and battery. The defense of some has been that they were merely doing what Trump had asked them to do, though the courts may reject that defense on the grounds that Trump was indeed as indirect (notwithstanding that he was just as clear) as Henry II.
If psychiatrists with decades of experience doing research on violent offenders do not confirm the validity of the conclusion that many nonpsychiatrists have reached, that Trump is extremely dangerous—indeed, by far the most dangerous of any president in our lifetimes—then we are not behaving with appropriate professional restraint and discipline. Rather, we are being either incompetent or irresponsible, or both.
However, while all psychiatrists, by definition, have studied mental illness, most have not specialized in studying the causes, consequences, prediction, and prevention of violence, which is considered a problem in public health and preventive medicine. Nor have most studied the principles on which the assessment of current and future dangerousness is based, regardless of whether any particular individual is mentally ill, and regardless of what diagnosis or diagnoses, if any, he may merit according to the criteria outlined in DSM-V.
That is why it is so important and so appropriate for those few of us who have done so—whether by investigating the psychology of Nazi doctors and Japanese terrorists, as Robert Lifton has done; or by studying sexual violence (rape, incest, etc.), as Judith Herman has done; or by examining murderers and rapists (including those who have committed “war crimes”) in prisons and jails throughout the world, as I did while working with the World Health Organization’s Department of Violence and Injury Prevention on the epidemiology and prevention of violence—to warn the potential victims, in the interests of public health, when we recognize and identify signs and symptoms that indicate that someone is dangerous to the public health.
One implication of this is that we need to identify the potential causes of injury and illness before they have harmed any given population of potential victims as severely or extensively as they would if allowed to go unchecked. In other words, we need to recognize the earliest signs of danger before they have expanded into a full-scale epidemic of lethal or life-threatening injury. The analogy here is to the proverb about how to get a frog to become unaware that it is being boiled to death: place it in a pot of cold water and then heat the water up bit by bit. Something analogous to that is the danger with the Trump presidency.
The United States has been blessed with a little over two centuries of democracy. That is actually a rather short period in comparison with the millennia of monarchy. However, it is long enough to have made most of us complacent, and perhaps overconfident, with respect to the stability of our democracy. In fact, if we are prone to making a mistake in this regard, we are far more likely to underestimate the fragility of democracy than we are to become unnecessarily alarmist about it.
Here again, it is the behavioral scientists who have studied violence (including but not limited to psychiatrists) who owe it to the public to share what we have learned before we experience the epidemic of violence that would be unleashed by the collapse or undermining of the rule of law, the system of checks and balances, the freedom of the press, the independence and authority of the judiciary, the respect for facts, the unacceptability of deliberate lying, the prohibition on conflicts between a political leader’s private interests and the public interest, and the even stronger prohibition on physically assaulting one’s political rivals or opponents and threatening to imprison or even assassinate them—in other words, dictatorship—all of which have been characteristic of Donald Trump’s public statements throughout his electoral campaign and presidency.
To wait until the water reaches boiling temperature, or our democracy collapses, before we begin saying anything about the fact that the water is warming already would mean that anything we said or did in the future would come too late to be of any help. Let us not make the same mistake that the German Psychiatric Association did in the 1930s.
There is an unfortunate and unnecessary taboo in the social and behavioral sciences generally against regarding politics and politicians as appropriate and legitimate subjects for discussion, inquiry, and conclusions. On the contrary, if a psychiatrist or psychologist, or any other behavioral scientist, expresses an opinion that is relevant to the political debates that occur in our country, he is likely to be accused of being “partisan” rather than “professional,” or engaging in a discussion that is “just political” rather than “scientific.”
I would argue that the opposite is true. At a time when more and more medical scientists are urging us to practice “evidence-based medicine,” isn’t it even more important that we learn to practice “evidence-based politics”? But of course we cannot do that unless we are willing to apply the methods and accumulated knowledge of all the social and behavioral sciences to this subject, and to publicize the conclusions we reach so that all our fellow citizens, which me
ans all our fellow voters, can benefit from the knowledge we have gained through our clinical, experimental, and epidemiological research into the causes and prevention of violence—concerning which data from politics and economics certainly figure prominently (Gilligan 2011; Lee, Wexler, and Gilligan 2014).
If we are silent about the numerous ways in which Donald Trump has repeatedly threatened violence, incited violence, or boasted about his own violence, we are passively supporting and enabling the dangerous and naïve mistake of treating him as if he were a “normal” president or a “normal” political leader. He is not, and it is our duty to say so, and to say it publicly. He is unprecedentedly and abnormally dangerous.
This is not to inform the public of something it does not already know, for most people in the lay public already appear to know it. Most voters voted against Trump. As our most recent Nobel Prize winner in Literature, Bob Dylan, has put it, “You don’t have to be a Weatherman to know which way the wind is blowing!”
In fact, Trump’s dangerousness is so obvious that he might be said to have preempted the role other people might otherwise have to play in warning the public as to how dangerous he is. For, in his many public statements on that subject, he himself has warned us about how dangerous he is far more clearly and eloquently than we have been able to do, or need to do. Our role here is not so much to warn the public ourselves, but merely to heed the warnings Trump himself has already given us, and to remind the public about them.